Genitourinary/Nephrology Flashcards
Presence of bacterial infection of urinary tract involving bladder
Cystitis
Presence of bacterial infection of urinary tract involving urethra
Urethritis
Presence of bacterial infection of urinary tract involving kidney
Pyelonephritis
What the most common bacterial agent of all childhood UTIs?
Escherichia coli
What are predisposing factors of UTI?
Immature kidneys associated with premature and low-birth-weight infants
Congenital urologic abnormalities, reflux, neurogenic bladder
Gender differences in anatomy of urinary tract predisposes females
Dysfunctional voiding
Functional obstruction
Trauma/irritants
What are newborn symptoms of UTI?
Irritability, poor feeding, diarrhea, fever, vomiting
What are infants/preschoolers symptoms of UTI?
Diarrhea, vomiting, fever, poor feeding, strong/foul-smelling urine
Fever, vomiting, strong/foul-smelling urine, suprapubic or urethral pain, frequency, dysuria, and incontinence
What are school-age children symptoms of UTI?
What are differential diagnosis of UTI?
Acute abdomen Chemical irritation Vulvovaginitis Dysfunctional voiding Sexual abuse Foreign body Pelvic inflammatory disease (PID) Dysfunctional elimination syndrome (DES)
What will urinalysis show for UTI?
Presence of urinary leukocyte esterase, nitrate, and blood suggestive of UTI
When is suprapubic aspiration used?
When infant/children who cannot void voluntarily when culture is needed urgently
What is considered positive in clean-catch midstream?
Colonies of 50,000-100,000 colony forming unit (CFUs)/mL of single organism
What is considered positive in straight catheterization?
Colonies > 10,000 CFUs/mL of single or multiple organisms
What is considered positive in suprapubic aspiration?
Colonies > 1,000 CFUs/mL of single of multiple organisms
When are radiologic studies needed to rule out UTI?
Symptoms of pyelonephritis regardless of age and gender
UTI in any child <3 months of age
Males with first infection and families with second infection, even if not pyelonephritis and child >3 months of age
What is the first step in imagining for UTI?
Bladder and renal ultrasound to evaluate structure and developmental anomalies/disorders
Detects regurgitation (reflux) of urine into ureter
What is voiding cystourethrogram (VCUG)?
When is VCUG indicated?
Renal and bladder ultrasonography reveals hydronephrosis, scarring, or other finds suggestive of VUR
Recurrence of febrile UTI
What are intravenous pyelogram (IVP) or nuclear renal cortisol scans looking for?
Detect scarring and examine renal function
Only done if VCUG is positive and possible renal scarring
When is acute dimercaptosuccinic acid (DMSA) used?
Done during time of infection to assess acute renal inflammation and/or uptake defects
Who needs parenteral antibiotics for UTI treatment?
Newborns, infants, or older children with vomiting or severe symptoms, systemic illness, fever, or unable to take fluids
What is the first-line drugs of choice for UTI older than 2 months old?
Trimethoprim-sulfamethoxazole (TMP/SMX) until sensitivities are available
What are other first-line drugs of choice for UTI?
Amoxicillin, amoxicillin/clavulanate, sulfisoxazole, cephalexin, nitrofurantoin
When should the first follow up urine culture be collected?
72 hours after initiating treatment if symptoms are not resolving
When do VUR grades I-III usually resolve?
Usually resolve as child grows if there is no underlying voiding or dysfunctional elimination syndrome
What are ways to prevent UTI?
Increased fluid intake
Frequent voiding with complete emptying of bladder
Good perineal hygiene with front-to-back wiping
Avoid bubble bath and other urethral irritants such as powders, sprays, products
Cotton underpants and avoidance of tight-fitting clothing that can irritate are recommended
Involuntary urination after child has reached age when bladder control is usually attained
Enuresis
Daytime enuresis
Diurnal
Nighttime, especially while sleeping enuresis
Nocturnal
When does enuresis typically resolve?
Age 5-7 years
At what age is enuresis considered abnormal?
After 7th birthday
What is primary enuresis?
Child has never attained nighttime dryness for a period of 6 months or more
What is secondary enuresis?
Recurrence of incontinence following a period of at least 6 months of dryness
What are common causes of primary enuresis?
Small bladder capacity
Toliet-training problems
Delayed maturation of voiding inhibitory reflex
Sleep problems (“deep sleeper”)
Lack of inhibition of antidiuretic hormone (ADH)
Ingestion of increased amounts of fluid
Dysfunctional voiding
What are common causes of secondary enuresis?
UTI, diabetes, GU abnormalities, family disruptions, stress
What are common medications of secondary enuresis?
Theophylline, diuretics
What are common signs and symptoms of enuresis?
Bedwetting or daytime urine leakage
Odor or urine on clothing and/or beeding
Withdrawal/isolation from peers, diminished self-esteem
Hypospadias, epispadias
Labial fusion
Dribbling of urine during examination
What are differential diagnosis of enuresis?
UTI Ectopic ureter Mechanical obstruction Dysfunctional voiding Dysfunctional elimination syndrome (constipation)
How do you diagnosis enuresis?
Urinalysis/urine culture
Renal ultrasound/vesicoureterogram
How to treat primary nocturnal?
Limit fluid intake after dinner
Double voiding before bedtime
Avoid punishment/criticism
Usually self-limited
Spontaneous resolution of 10% per year after 5 years of age
What therapies can be used to treat enuresis?
Motivational therapy–verbal praise for dryness, reward system, dryness calendar
Conditioning therapy–triggered by urine, children awakened by alarm, alarm sensitizes child to sensation of full bladder
What pharmacologic treatment for enuresis?
Desmopressin acetate
Imipramine
Absence of one or both tests in scrotal sac due to failure of normal descent from abdomen during fetal development
Cryptorchidism
What are differential diagnosis for cryptorchidism?
Retractile testes
Ectopic testes
Aorchia
Chromosomal disorders
What do palpable testes with cryptorchidism signal?
May be retractile or ectopic
What do non palpable testes with cryptorchidism signal?
May be abdominal or absent
When does spontaneous descents usually occur for cryptorchidism?
By 6 months
What treatments for cryptorchidism if not descended by 1 year?
Hormonal therapy or surgical intervention (orchiopexy)
What are the potential complications for cryptorchidism?
Infertility
Testicular malignancy
Hernia
Painless scrotal swelling due to collection of peritoneal fluid within tunica vaginalis surrounding scrotum?
Hydrocele
What is noncommunicating type hydrocele?
Tunica vaginalis is closed, limiting fluid collection to scrotum; size of hydrocele is constant
What is communicating type hydrocele?
Tunica vaginalis remains open, allowing fluid to flow between peritoneum and hydrocele sac; associated with hernia
Swelling in scrotum (alternating or fixed) that may be painful if full or tense secondary to coughing or straining
Smaller on awakening and enlarges as day progresses
Fluctuance
Translucent with transillumination
What are signs and symptoms of hydrocele?
What are differential diagnoses for hydrocele?
Cryptorcidism Retractile testes Hernia Inguinal lymphadenopathy Patent processus vaginalis
What is management for noncommunicating hydrocele?
Most resolve spontaneously without intervention
Refer is persists beyond 1 year, increase in size, or causes discomfort
What is management for communicating hydrocele?
Occasional spontaneous resolution
Frequently develops into hernia requiring surgical intervention
Refer for surgical evaluation if persist beyond 1 year
Congenital defect with urethral meatus on ventral surface of penis
Hypospadias
Which population does hypospadias typically occur?
Caucasians
What is the management for hypospadias?
Avoid circumcision; refer to pediatric urology
For mild cases, primarily cosmetic surgery
For increasing severity, functional, psychological, and cosmetic surgery–repair early 6-18 months
Narrow, non retractile foreskin of childhood; not fully retractable to expose glans
Phimosis
Uncircumcised newborns may not be able to be able to fully retract until WHAT AGE?
10 years or older
Inability to replace foreskin over glands after retraction
Paraphimosis
What are signs and symptoms of phimosis?
May be asymptomatic, painful urination, weak urine stream, ballooning of foreskin when urinating
What are signs and symptoms of paraphimosis?
Pain/tenderness
What are differential diagnoses of phimosis/paraphimosis?
Balanitis
Balanoposthitis
How do you treat phimosis?
Maintain good hygiene
Only gentle stretch of foreskin during bath
If there is urinary obstruction, circumcision may be required
What is the treatment for paraphimosis?
Goal: reduction of swelling to reduce foreskin
Ice, application of granulated sugar to penis, or wrapping distal penis in saline-soaked gauze and applying pressure for 5-10 minutes
Injection of hyaluronidase beneath the band to release it
Narrowing of distal end of urethra
Meatal stenosis
What the most common cause of meatal stenosis?
Postcircumcision 11%
What are signs and symptoms of meatal stenosis?
Penile pain/discomfort with urination
Narrow, dorsally diverted urine stream
High-velocity urine stream
Occasional bleeding following void
Inflammation of glands
Slit-like or narrowed meatus
What are differential diagnoses for meatal stenosis?
Hypospadis
Chordee
What is treatment for meatal stenosis?
Air exposure
Warm soaks/baths
Frequent diaper change
Meatotomy may be necessary
Torsion of spermatic cord that can result in gangrene of testes (emergency)
Testicular torsion
When does testicular torsion usually occur?
In adolescent males
What is common signs and symptoms of testicular torsion?
Acute, painful swelling of scrotum
Nausea, vomiting, anorexia
Minimal fever
Lack of urinary symptoms is normal
What are common presentation for testicular torsion?
Not unusual to awaken with pain, but can develop after scrotal trauma or increased activity
What are differential diagnoses of testicular torsion?
Trauma
Ochitis
Acute epididymitis
Hydrocele
What are physical findings of testicular torsion?
Enlarged, highly render testis
Scrotum on involved side edematous, warm erythematous
Anxious patient, resistant to movement
Lifting testis does not relieve pain
Solid mass may be visualized with transillumination
What is Prehn’s sign?
Lifting testis does not relieve pain
What are diagnostic testing for testicular torsion?
CBC–slight increase in WBC
Doppler ultrasound–diminished blood flow
Urinalysis–usually normal
What is management for testicular torsion?
Immediate surgery referral within first 6 hours
Blood in urine is visible to naked eye that causes urine to appear tea or cola colored
Gross hematuria
Blood is not visible with naked eye, but is detectable with a microscope; can be persistent or transient
Microscopic hematuria
What are signs and symptoms of hematuria?
Visible blood in urine; may be found in urinalysis prompted by urinary or other symptoms
Pain varies with many children experiencing no pain and some children reporting discomfort/pain
What is treatment for hematuria?
Infections are treated with antibiotics
Trauma with dramatic injury to kidney or bladder–surgical intervention
Stones treated depending on type, size, and location–prevention further stones
Trauma with bruising but no laceration to kidney will require only rest and appropriate time to heal
Kidney disease treated with situational- and stage-appropriate interventions
What will urine dipstick/reagent strip show for hematuria?
Can detect 5-10 intact RBCs/micro L
What will microscopic exam show for hematuria?
Positive dipstick result is confirmed by microscopic examination of sediment of 10-15 ml of centrifuged fresh urine
Presence of abnormal levels of protein in urine; more than 100-150 mg/m2/day
Proteinuria
What are causes of transient proteinuria?
Idiopathic, fever, seizure, vigorous exercise, dehydration, stress, cold exposure
What are causes of persistent proteinuria?
Glomerular factors related to nephron loss, reflux nephropathy related to VUR, Alport syndrome, glomerulopathy, infection, malignancy, toxin
What are signs and symptoms of proteinuria?
Usually asymptomatic
Change in urine volume, change in urine color, increased BP or edema, recent streptococcal infection
What are differential diagnoses of proteinuria?
Transient proteinuria Orthostatic proteinuria Persistent proteinruia Diabetes mellitus Glomerulopathy Vascular disease or vasxulitis Alport syndrome Nephron loss (due to disease, infection, insult)
What does urine dipstick show for proteinuria?
Greater than or equal to 1+
What does quantitative urine assessment for proteinuria?
May show persistent dipstick positive proteinuria; limited use to difficulty in accurately and completely collecting 24 hours of urine
What does sulfosalicylyc acid show for proteinuria?
Measures all proteins in urine but is infrequently use din children
What is treatment for transient proteinuria?
Retest in 1 year to confirm
What is treatment for persistent proteinuria?
Refer to pediatric nephrologist
Disease characterized by diffuse inflammatory changes in glomeruli that is immune-mediated response
Glomerulonephritis
What is the most common cause of primary acute glomerulonephritis?
Poststreptococcal glomerulonephritis
What is the chronic form of glomerulonephritis normally seen in?
Immunoglobulin A (IgA) nephropathy
What are signs and symptoms of acute glomerulonephritis?
Hematuria
Decreased urine output
Edema
Dark urine (acute poststreptococcal glomerulonephritis (APSGN))
What are signs and symptoms of chronic disease of glomerulonephritis?
Fatigue
Failure to thrive
What are differential diagnoses of glomerulonephritis?
Benign hematuria Hereditary nephropathy Systemic lupus erythematosus Anaphylactoid purpura IgA nephropathy Henoch-Schonlein Purpura (HSP)
What are physical signs of glomerulonephritis?
Gross hematuria
Facial (periorbital) edema in the morning
Hypertension with or without renal insufficiency
Costovertebral angel (CVA) tenderness
What are results of urinalysis for glomerulonephritis?
Cast--RBCs, leukocytes, and/or casts Hematuria Protein low pH Increased specific gravity
What will titers show for glomerulonephritis?
Serum antistreptolysin O (ASO)
Anti-strepto hyalurinodase test (AHT)
anti-DNase B
What will chest radiograph show for glomerulonephritis?
Pulmonary edema
What will management be for glomerulonephritis?
Hypertension/relieve edema–fluid restriction, diuretics, vasodilators
Antibiotics–penicillin if throat and skin infection persists
Unilateral or bilateral dilation of kidney(s)
Hydronephrosis
Anatomic block of urine from kidney or back flow of urine into kidneys as in VUR
Hydronephrosis
What is the most common site of obstruction for hydronephrosis?
Ureteropelvic junction (UPJ)
What are signs and symptoms of hydronephrosis?
Nusea Abdominal/flank pain Decreased urine output Failure to thrive VUR Posterior urethral valves
What are differential diagnoses for hydronephrosis?
Prune belly syndrome UPJ obstruction Ectopic ureterocele Urethral/uretrrovesicular obstructions BUR Posterior urethral valves
What is treatment for hydronephrosis?
Surgery to relieve obstruction
Must follow-up long-term for continued assessment of renal function
Detect in normal urine acidification with resulting persistent metallic acidosis
Renal tubular acidosis
What is type 1 renal tubular acidosis (RTA)?
Defect in distal tube secretion of hydrogen ions
What is type 2 renal tubular acidosis (RTA)?
Defect in reabsorption of bicarbonate
What are signs and symptoms of renal tubular acidosis?
Growth failure
GI complaints
Muscle weakness
What are differential diagnoses for renal tubular acidosis?
Diarrhea
Diabetes mellitus
Renal failure
Lactic acidosis
What will urine pH show for renal tubular acidosis?
First morning specimen
pH <5.5 = proximal RTA
pH >5.7 = distal RTA
What will electrolytes look like for renal tubular acidosis?
Serum bicarbonate less than 16 mEq
Hyperkalemia
What is the goal for renal tubular acidosis?
Achieve optimal growth and bone mineralization and prevent nephrocalcinosis and progression to renal failure
How do you treat acidosis for renal tubular acidosis?
Balance serum bicarbonate to normal level
What are risk factors for renal tubular acidosis?
Risk of nephrocalcinosis, renal failure due to continuous alkali therapy and long-term clinical monitoring
What does high-grade vesicoureteral reflux result in?
Renal scarring, eventual hypertension, and renal failure
What does a febrile infant with UTI undergo?
Renal and bladder ultrasonography
What are the most common oral antibiotics for UTI?
Trimethroprim/sulfamethoxazole Cephalosporins Amoxicillin Sulfisoxazole Nitrofurantoin
How soon do you need to follow up for UTI?
2 days
Who classifies as a need for renal ultrasound after first UTI?
febrile infants
children 2-24 months (whether febrile or not)
What is chordee?
Ventral bowing of penis
What are signs and symptoms of hypospadias?
Dorsally hooded foreskin
Urinary stream that aims downward
What is the best age to do surgery for hypospadias?
Around 6-12 months
If there is bilateral cryptorchidism, what should be done?
Karotyping for chromosomal abnormalities
What children at risk for with cryptorchidism?
Testicular cancer
When pain is relieved by elevated scrotum, what should be expected?
Epididymitis
When pain is not relieved by elevating scrotum, what should be expected?
Testicular torsion
What is primary dysmenorrhea?
Absence of any pelvic pathology
Etiology is thought to be hormonal and endocrine-related
Most causes begin 6-12 months after menarche with symptoms gradually increasing util patient are in mid-20s
What are sign and symptoms of dysmenorrhea?
Painful menses
Lower abdominal pain associated with menstruation, usually worse in the first few days of bleeding
Back pain
Nausea, vomiting, fatigue, headache, diarrhea
What do you treat dysmenorrhea?
Heat application
Psychological support
OTC analgesics (ibuprogren 400 mg Q4-6hr, best to start 2 days before cycle and continue until 2 days after cycle finishes)
Stronger NSAIDs for moderate to severe cases
Oral contraceptives
